Covid-19 Consent Form, AMAC

AMAC

COVID-19 Vaccine Patient Screening/Vaccine Administration Record
Vaccine Location *
Patient Information
Patient/Vaccine Recipient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Gender
Patient Race/Ethnicity
Patient Address *

Address

Street Address Line 2

City

Zip
Patient Email (this is how we will send you updates regarding your appointment) *
example@example.com
Patient Phone Number *
Please enter a valid phone number.
Insurance Information

Please ensure to record both pharmacy and medical insurance information since there are multiple ways that the vaccine can be billed at the pharmacy

Insurance Information *

	Pharmacy	Medical
Insurance Plan Name
Member/Recipient ID
RX Bin
RX PCN
Group number

If you have Medicare (Red, White & Blue Card) #
Are you the Medicare Card Holder?

Yes No
If no, please provide cardholder's name, date of birth, and relationship:
Insurance Cardholder Name
Cardholder DOB

Month Day Year
Date
Cardholder Relationship to Patient
Patient Consent

I understand the benefits and risks of the vaccination as described in the Emergency Use Authorization (EUA) and/or CDC Vaccine Information Statement (VIS), a copy of which was provided with this Consent and Release. I request the vaccine be given to me or the person named below, a minor for whom I represent that I am authorized to sign this Consent and Release.
Signature of Person to Receive Vaccine (or Parent/Guardian, if a minor) *

Clear
Date *

Month Day Year
Date
Print Parent/Guardian name if recipient is a minor
Receipt of Privacy Practices

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and my rights with respect to my health information, including reporting to the State Vaccination Registry and/or local or state Departments of Heath, federal Department of Health and Human Services, and the Center for Disease Control and Prevention.
Signature of Person to Receive Vaccine (or Parent/Guardian, if a minor): *

Clear
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